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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173001847
Report Date: 08/07/2023
Date Signed: 08/07/2023 09:37:54 AM

Document Has Been Signed on 08/07/2023 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NCO HEAD START - UPPERLAKEFACILITY NUMBER:
173001847
ADMINISTRATOR:MICAH HALEFACILITY TYPE:
850
ADDRESS:629 SECOND STREETTELEPHONE:
(707) 275-2721
CITY:UPPERLAKESTATE: CAZIP CODE:
95485
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
08/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Child Development Supervisor, Hyechong Froschl & Site Supervisor, Micah Hale TIME COMPLETED:
09:40 AM
NARRATIVE
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On 05/22/2023, Licensing Program Analyst (LPA), Sebastian Phouthavong made a case management inspection and met with Child Development Supervisor, Hyechong Froschl & Site Supervior, Micah Hale. The inspection was made in response to water lead testing results received from the facility. The test results showed that the following simples tested above the allowable level 5.0 parts per billion (ppb) of lead in the water: Sample Site "D” had a reading of 27 ppb. All other sources of water tested below the allowable level of 5.0 ppb.

During today’s inspection, LPA observed Simple Site “D”, the childcare bathroom sink faucet replaced and in use for hand washing. Child Development Supervisor stated the Simple Site "D" was replace and flushed out for 30 days. The 2nd retest for Simple Site "D" was conducted in 03/2023 and resulted in ND (Not Detected).

The facility has submit the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to CCL.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Supervisor, Micah Hale.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2023 09:37 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 08/07/2023 at 09:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NCO HEAD START - UPPERLAKE
FACILITY NUMBER: 173001847

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1) A result with values of 5.0 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
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Plan of Correction as been completed. The facility as replaced bathroom sink (Site “D”) and retested resulting in ND (Not Detected)
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Based on record review, facility bathroom sink (Site “D”) exceeded the allowable levels of lead in the water, testing at 27 ppb. This is a potential health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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